Good News: ABA Benefits Through Insurance Not Affected by ACA

Posted on Sunday, April 13, 2014

Good News: ABA Benefits Through Insurance Not Affected by ACA

After more than two years of work by advocates, the Autism Society of Boulder County is excited to announce that last week the Division of Insurance (DOI) issued Bulletin No. B-4.71 to clarify issues that have surrounded the implementation of the Affordable Care Act (ACA) and Health Insurance Mandated Autism Treatment (HIMAT). The advocacy community is grateful for the time and energy that DOI Commissioner Marguerite Salazar and her staff have spent on this issue.

Many families, providers and advocates had expressed concern with the DOI’s conversion of monetary benefits for Applied Behavior Analysis (ABA) to session limits. The new bulletin clarifies that:

"All carriers issuing individual and/or group health benefit plans must provide, at a minimum, $34,000 annually in ABA therapy benefits for children through age eight (8), and $12,000 annually in ABA therapy benefits for children aged nine (9) up to age nineteen (19), regardless of the number of visits required to reach these minimum benefit amounts.
The current minimum number of visits, in twenty-five (25) minute increments, established by rule is five hundred fifty (550) visits for a child through age 8, and one hundred eighty five (185) visits for a child aged nine (9) up to age nineteen (19).

If the minimum ABA therapy benefits of $34,000 or $12,000, as applicable, have not been provided when the minimum number of visits has been reached, additional visits must be authorized until, at a minimum, $34,000 or $12,000, as applicable, in ABA therapy benefits have been provided. Nothing in Colorado law or regulation prevents a carrier from providing more than the minimums established by rule. 
Nothing in this bulletin or in Colorado Insurance Regulation 4-2-47 prohibits a policyholder from requesting or receiving additional ABA therapy above the $34,000/550 visit minimum from a carrier. This bulletin and Colorado Insurance Regulation 4-2-47 should not be construed as the Division taking a position regarding whether federal law requires carriers to cover medically necessary ABA therapy in excess of the $34,000/550 visit minimum required by Regulation 4-2-47."

What does this mean for families?
The intent of this bulletin is to give guidance to carriers to protect your ABA benefits. Your benefits should not be reduced as a result of the ACA implementation. In fact, this bulletin emphasizes that these session limits or monetary limits should be thought of as MINIMUMS. It also draws a parallel between services that were received under the previous monetary caps ($34,000/$12,000). The bulletin does not prohibit families from requesting additional ABA services (over the $34,000/550) as needed from the carriers, although it does not guarantee that they will be covered. The information gleaned from multiple hearings is that additional work is still being done to assess these minimums. 
Undoubtedly, there will still be need for support and advocacy around this matter. Please continue to contact or with any questions or concerns.


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